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ACTIVITY UNCHANGED FROM FY2009 Pathfinder (PI) in COP09 supported PMTCT activities in a total of ten facilities (three General Hospitals and seven Primary Health Centers) in three local government areas (LGAs) of Edo state. In COP10, Pathfinder will strengthen these sites and networks to provide quality PMTCT services and community outreach activities. The PMTCT Facility Management Committee in each focal health facility will be strengthened for project sustainability. This will support the community component of health system strengthening shaping the demand element of communities for responsiveness and fair distribution of service delivery.

The PMTCT activity will promote gender equity in HIV/AIDS programs and increase access to services by the vulnerable groups of women and children. It will help increase service uptake, promote positive male norms and behaviors, especially as it relates to discordant couples, and help reduce stigma and discrimination while building community ownership and sustainability.

Interventions to be carried out during year three by Pathfinder International in Edo State are described below, including activities that are being carried over from year two.

Objective 1: Prevent new HIV infections and provide quality comprehensive care to HIV + pregnant women and mothers

1.1 Advocacy and Sensitization To expand availability, access and use of PMTCT services, Pathfinder will work with facility, community,

and local authorities (including traditional and government leaders) to continue building support and acceptance for services. Advocacy, as in previous years, will target all the key stakeholders at Edo state and LGA ( Owan East and Ovia South West) levels including the Local Government Council members, the Legislature and communities will be mobilized to garner support for PMTCT services. In addition, the importance of PMTCT to all family members including all pregnant women to attend ANC and access PMTCT services will be reiterated.

Advocacy efforts will include securing the support of the leaders for the strengthening of the PMTCT Facility Management Committees which are expected to play a greater role in the reporting of Primary Health Care services within other beneficiary committees.

1.2 Facility Supplies Support Effective supportive supervision will identify gaps in equipment and material resources as quality PMTCT services continue to be provided to the populace at the supported sites. The project will provide necessary supplies required to fill these gaps, as well as ARVs and test kits for quality PMTCT service delivery. This may include materials for universal precautions for infection prevention and consumables.

1.3 Technical and Management Training for Facility Staff

PMTCT/HTC Updates for Facility staff Knowledge and skill updates serve as a way of providing further support for technical persons and addressing some of the gaps identified during monitoring and supervision. A 3 day update training on PMTCT and HTC to further increase their knowledge and sharpen their skills is planned. This training will utilize a consultant from the national pool of trained PMTCT trainers.

Laboratory Updates for Facility staff In addition, a 2 day update training will take place (facilitated by a consultant) for laboratory scientists and technicians on laboratory safety skills using on-site training approach.

1.4 Update meetings for four different groups: PHCs, Private practitioners, TBAs and male motivators A one-day update meeting for these different target groups will hold to provide the groups on progress and for discussing opportunities and challenges that have arisen in the last year. Using a participatory approach, new strategies will be developed to increase ANC attendance & PMTCT clientele at supported facilities.

1.5. Provision of PMTCT services Pregnant women, postpartum mothers, their partners including HIV exposed infants and HIV infected

children will be targeted and supported so that they have full access to HTC at multiple entry points of care. HTC will be done for pregnant women on a three-monthly basis till she delivers. Pregnant women are being supported to deliver in health facilities through the provision of the national safe motherhood program delivery kits ("mama kits") presently supplied by the LGA authority. The use of ART for PMTCT will follow the National PMTCT guidelines. Women presenting at labor will be offered rapid testing and if HIV-infected provided with SD-NVP.

All infants born to HIV-infected women will receive SD-NVP at birth and AZT for 6 weeks. An estimated 70 mother-baby pairs will receive ARV prophylaxis. During ANC, HIV positive women will receive counseling on infant feeding options and after delivery will be supported to initiate whatever option she settles for before going home. Promotion of Nutritional support in terms of nutritional counseling and referring for food support will be offered.

Health facilities will be supported to provide basic laboratory services and will be linked to a laboratory network model in which CD4 testing can be performed via specimen transport systems. In addition, linking with FP counseling and service provision and effective condom promotion (including post-partum FP) will be done. Exposed infants will be actively linked to pediatric care and treatment through under-5 cards issued in labor and delivery.

Pathfinder will work in close partnership with IHV and the Clinton Foundation on HIV infant diagnosis and referrals for HIV infant diagnosis testing through a Dried Blood Spot (DBS) from 6 weeks of age. HIV positive infants will be linked to appropriate care and treatment.

1.6 Strengthen Referrals and Linkages The referral network developed in the previous two years will still be utilized to aide the facilities and communities in making and accessing referrals.

Referrals: The entry point for recruiting pregnant women for the program include - during community mobilization, ANC and personal contact by the community resource persons. When a HIV + pregnant woman is identified during a community mobilization event she is referred to the facility for continued care by the team and, if permission is granted, her contact information obtained. The lay counselor provides follows up support to encourage women to access services. Other women who show up at the clinic (perhaps from community mobilization or TBA and personal contacts) are also counseled and tested and those that are positive are enlisted in the program for follow-up. Other HIV + pregnant women who already knew their status before being pregnant are referred to the comprehensive care and support centres.

Linkages will be established for services that the Pathfinder program cannot provide. Such services will include CD4 count; ART support after delivery for women who tested positive during that pregnancy; facility and community based care and support services; and pediatric follow-up. This will be coordinated centrally by each M & E focal person of the LGA /GH with the involvement of the respective PHC M& E focal persons. The above tasks will be facilitated by the provision of a minimal amount on recharge cards. The M&E focal persons for the focal health facilities will ensure validation of referrals from PHCs to other centres, either secondary or tertiary. They will also track clients who deliver with TBAs to ensure Nevirapine compliance when in labor.

1.7 Expanding the PMTCT Facility Management Committee The PMTCT Facility Management Committee existing in each focal health facility for the last two years will be expanded to include more members from the surrounding community so as to strengthen it as a coalition. They were set up to facilitate community involvement and ensure successful program implementation by exchanging information and reviewing data trends of the facility and at the same time doing a SWOT analysis. By including more members of the community, these committees will strengthen their functions for effective advocacy, mobilization and communication, and fundraising so as to also consider issues of sustainability for provision of quality services to the populace including the source or raise of funds if necessary and liase with government and other voluntary agencies in finding solutions to health and social issues.

1.8 Community Mobilization (in all ten health- facility communities) Community mobilization activities will create awareness and demand for PMTCT services. Health facilities will be supported to organize sensitization events including rallies using special days like World AIDS Day, Safe Motherhood Day, Women's Day and during Breast Feeding Week. During these events, mobile HCT clinics will be present to provide on-the-spot voluntary counseling, testing and receipt of results. Post-test counseling will include how to stay HIV negative, motivation to accept PMTCT services, effective 'spousal communication' and partner testing at the static T & C sites. If positive, referrals will be made to adult ART centers and other counseling and support services for non-pregnant women and for pregnant women to the project facilities.

1.9 Outreach services to nearby PHCs and private clinics Visits to PHCs and private health clinics in a 20 km radius of the focal health facilities will also be carried out by health care providers in order to provide PMTCT in terms of HIV testing and if found to be HIV positive, provision of ARV prophylaxis drugs to such individuals. Follow-up will be carried out to offer ARV prophylaxis to babies born to HIV positive mothers.

1.10 Quarterly network meetings of PLA support group PLA support groups of year two will liase to form coalitions with other PLA support groups in the LGA and/or neighbouring LGAs that promote psychosocial and emotional support, to share experiences and to strategize ways of reducing stigma and motivate members to disclose their status.

1.11 Project Review Meeting At the end of year 2, a stakeholder meeting will be held in each LGA to review the project through the last year of implementation. Joint discussions will plan the way forward in order to reach the goal and objectives of the project by bringing all the key persons involved in project implementation and reviewing where the project stands in terms of deliverables.

Monitoring and Evaluation: Pathfinder International had strengthened its internal M&E system in COP09 by integrating its database with the National District Health Information System (DHIS) software for electronic data capture and GIS application, data quality and data use for improvement of service delivery. Data managers of Pathfinder International including the Edo state focal person for the project were trained by on its importance and use. On this project, the Country M&E Specialist will continue to ensure consistent and continuous reporting and monitor each step of the way and expand to include the additional facilities while at the same time ensuring quality data through continuous on-site technical support and data quality assurance checks at all levels of data collection, collation, use and reporting. Data information and analysis will be shared with facility managers, the LGA M&E officer, SACA and SASCP.

Code Objective/Key Indicator Target Year 3 Objective 1: Prevent new HIV infections and provide quality, comprehensive care to HIV+ pregnant women and mothers. P1.1.D Number of pregnant women with known HIV status( includes women who were tested for HIV and received their results) 3384 P1.2.D Number of HIV-positive pregnant women who received antiretroviral to reduce risk of mother-to- child transmission 70 P1.1.N Percent of pregnant women who were tested for HIV and know their results. 90 P1.2.N Percentage of HIV-positive pregnant women who received antiretrovirals to reduce the risk of mother-to-child transmission 85

If additional funds are granted, the M& E system will be strengthened within this technical area ( Budget amount estimate: $35,000.00)

For effective management of health and resources, government at all levels must have interest in supporting and ensuring that health data and information are available as a public good for all stakeholders to utilize. Availability of accurate, reliable, timely and relevant health information is the most fundamental step towards informed public health action. Over the years, planning monitoring and evaluation of health services and programmes have been hampered by dearth of reliable data. National Health Management Information System (NHMIS) is to provide reliable, relevant and timely information to health system's policy makers, managers, professionals, and to the other sectors. Health workers need to have proper orientation on District Health Information System (DHIS) and be motivated to play their own roles in data collection, collation, analysis and dissemination.

Therefore, to help strengthen the M&E system towards meeting the national reporting needs, the capacity of health workers at state and LGA need to be enhanced through the activities proposed below. 1. A five-day 'Basic M& E and orientation to DHIS' Training for 24 health care workers (from the focal health facilities) including the LGA M&E officers on the use of DHIS software for electronic data capture is planned. This training will be delivered by a consultant and hold in Benin. 2. A three-day 'GIS application and data use' Training of the same group and health facility managers and PHC coordinators on GIS application, data quality and data use for improvement of service delivery. This will be delivered using PI in-house capacity and hold in Benin.

Additional performance indicator would then be :

Code Objective/Key Indicator Target Year 3 H2.3.D Number of health care workers who successfully completed an in-service training program (M&E) 24